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ORIGINAL ARTICLE
Year : 2019  |  Volume : 22  |  Issue : 7  |  Page : 920-925

Pattern of renal diseases in children attending paediatric nephrology clinic of Aminu Kano Teaching Hospital, Kano


1 Department of Paediatrics, Bayero University and Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Paediatrics, Federal Medical Center, Katsina, Nigeria

Date of Acceptance25-Mar-2019
Date of Web Publication11-Jul-2019

Correspondence Address:
Dr. P N Obiagwu
Department of Paediatrics, Aminu Kano Teaching Hospital, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_538_18

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   Abstract 


Background: The pattern of pediatric kidney diseases varies from one region to another because of genetic, racial, and environmental differences. This study was aimed at determining the pattern of renal diseases among children presenting at the pediatric nephrology clinic of the hospital. Subjects and Methods: It was a retrospective study of all children aged less than 15 years seen at the pediatric nephrology clinic of the hospital over a period of 30 months. The records of 244 patients seen at nephrology clinic over the period of study were retrieved and studied. Results: There were 155 males (63.5%) and 89 females (36.5%), with a male to female ratio of 1.7:1. The ages ranged between two months and 179 months, with a mean age of 104.8 ± 46.7 months. Nephrotic syndrome was the commonest renal disease and accounted for 33.6% (n = 82) of all cases, followed by acute glomerulonephritis with 25.8% (n = 63). Acute kidney injury and chronic kidney disease follow with frequencies of 34 (13.9%) each. The commonest congenital anomaly of the kidneys was ectopic kidney with 12 cases (4.9%). Conclusions: Our data reflects a high burden of renal diseases among children in our environment, and also reflects variations in regional patterns. The need for improvement of pediatric renal services and training of health workers in early detection and treatment of these conditions cannot be overemphasized.

Keywords: Out-patient clinics, pediatric, pattern, renal diseases


How to cite this article:
Obiagwu P N, Lugga A S, Abubakar A A. Pattern of renal diseases in children attending paediatric nephrology clinic of Aminu Kano Teaching Hospital, Kano. Niger J Clin Pract 2019;22:920-5

How to cite this URL:
Obiagwu P N, Lugga A S, Abubakar A A. Pattern of renal diseases in children attending paediatric nephrology clinic of Aminu Kano Teaching Hospital, Kano. Niger J Clin Pract [serial online] 2019 [cited 2019 Jul 20];22:920-5. Available from: http://www.njcponline.com/text.asp?2019/22/7/920/262527




   Background Top


Renal diseases are important causes of morbidity and mortality among children worldwide, more so in the developing countries where such factors as late presentation, limited diagnostics, and therapeutics among others contribute to the high burden and poor outcome of renal diseases in children.[1]

The pattern of pediatric kidney diseases varies according to genetic, racial, environmental differences, as well as geographical locations.[2] Data on the spectrum of renal disorders in African children are scanty, but many recent studies suggest that renal diseases are common and that the incidence may be rising.[3] Several authors have carried out studies on the pattern of renal diseases in children in Nigeria, and report varying patterns of occurrence of the acquired renal diseases among children.[1],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12] The most commonly reported renal diseases are nephrotic syndrome, acute glomerulonephritis (AGN), acute kidney injury (AKI), and urinary tract infection, whereas the most commonly reported malignancy is nephroblastoma.[5],[6],[9] Congenital anomalies of the kidneys and urinary tract (CAKUT) are less frequently encountered.[13]

The pattern and burden of childhood renal diseases has not been studied in our region. This study therefore was aimed at determining the pattern of renal diseases among children presenting at the pediatric nephrology clinic of the hospital.


   Subjects and Methods Top


This was a retrospective study of all children aged less than 15 years seen at the pediatric nephrology clinic of the hospital over a period of 30 months from January 2015 to June 2017. Records of these patients recorded in a clinic register were retrieved and reviewed. Data extracted included age at presentation, gender, and diagnosis. Records of socioeconomic class were largely incomplete in the clinic records and thus data on socioeconomic class was not studied.

The pediatric nephrology clinic of the hospital runs once a week. The pediatric nephrology team comprises two consultant pediatric nephrologists and four resident doctors, with interns also rotating through the unit. Patients seen at the clinic are those referred from the outpatient department of the hospital, those referred from other hospitals within the state, those referred from other states in northern Nigeria where there are no specialists, patients admitted with renal diseases who were discharged to the clinic, as well as patients from other specialties with coexisting renal conditions. The unit is equipped to carry out several diagnostic and therapeutic procedures which include renal biopsy, peritoneal dialysis, and hemodialysis, as well as research.

For the purposes of this study, the different renal diseases had to meet the standard case definitions. Nephrotic syndrome was defined as the presence of heavy proteinuria (urine protein of 40 mg/m 2/h or proteinuria on urine dipstick of ≥3+), hypoalbuminemia (serum albumin <2.5 g/100 ml), and generalized edema.[14] AGN was defined as hematuria or red blood cell casts accompanied by hypertension, edema, and impaired renal function. Urinary tract infection (UTI) was defined as the growth of 100,000 or more colony forming units (CFU) of a single organism per milliliter of a midstream/clean catch urine sample or the growth of any amount of bacteria from urine specimen obtained by suprapubic collection.[15] AKI was defined as sudden deterioration of renal function evidenced by increase in serum creatinine to ≥1.5 × upper limit of normal (≥3.0 mg/dl) or oliguria defined by urine output of <0.5 ml/kg/h for at least 6 hours.[16] Chronic kidney disease (CKD) was defined as abnormalities of kidney structure or function (albuminuria, urine sediment abnormalities, electrolyte, and other abnormalities due to tubular disorders, abnormalities detected by histology, structural abnormalities detected by imaging, history of kidney transplantation), present for >3 months.[17] To avoid recruiting a patient more than once, where a patient has more than one of the disease entities defined above, the diagnosis was considered based on the primary disease, for example, AGN, and not AKI for those with AGN and AKI. An exception to this was in the case of CKD, which was considered instead of the primary disease entity causing it.

Data obtained were analyzed using the Software Package for Social Science (SPSS) version 24.0 for Windows ® (IBM software, USA). Continuous variables were analyzed and expressed as mean and standard deviation. Comparison of mean was done using the Student's t-test. The Chi-square test was applied to compare the data of proportions. A P value <0.05 was considered significant. Results were presented as tables and bar charts. Ethical approval was obtained from the hospital ethics committee.


   Results Top


A total of 244 new patients were seen at the pediatric nephrology clinic over the 30-month period. There were 155 males (63.5%) and 89 females (36.5%), giving a male to female ratio of 1.7:1. The ages ranged between two months and 179 months, with a mean age of 104.8 ± 46.7 months. Most patients (45%) were aged 120--179 months.

Nephrotic syndrome was the most frequently encountered renal disease and accounted for 33.6% of all cases, followed by AGN with 25.8%. AKI and CKD follow with same frequencies of 13.9% each. Nineteen children (7.8%) had congenital anomalies of the kidneys, ectopic kidney being the most commonly encountered with 12 cases (4.9%). All the acquired kidney diseases were commoner among males. There were more females with CAKUT than males. This difference was, however, not statistically significant (Chi-square χ2 = 0.691, P = 0.406). Ectopic kidneys were commoner among girls, polycystic kidney disease was encountered only among girls, posterior urethral valve was exclusively among boys and congenital solitary kidney was seen equally among both sexes. [Table 1] shows the spectrum and gender distribution of all renal diseases in the study population. [Figure 1] shows the spectrum of congenital anomalies of the kidneys and the urinary tract while [Figure 2] shows the spectrum of acquired renal diseases in the study population.
Table 1: Spectrum and gender distribution of renal diseases in the study population

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Figure 1: Spectrum of congenital anomalies of the kidneys and the urinary tract in the study population

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Figure 2: Spectrum of acquired renal diseases in the study population

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The mean (SD) age at presentation was 104.8 (46.7) months. One hundred and ten children (45.1%) presented in adolescence. Children with CKD presented at much older ages than children with other conditions. The children with PUV were the youngest at presentation. [Table 2] shows the distribution of renal diseases by diagnosis and age.
Table 2: Distribution of renal diseases by diagnosis and age at presentation

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On comparative analysis of the two most common disease conditions in the study population, nephrotic syndrome, and AGN, there was no significant difference in terms of age and gender. This is depicted in [Table 3].
Table 3: Comparative analysis of nephrotic syndrome and acute glomerulonephritis.

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The mean age of presentation of CAKUT was significantly lower than that of acquired kidney disease (χ2 = 2.031, P = 0.025). There was, however, no statistically significant difference in terms gender distribution between CAKUT and acquired kidney disease (χ2 = 0.691, P = 0.406). This is shown in [Table 4].
Table 4: Comparative analysis of congenital and acquired kidney diseases

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   Discussion Top


The findings of this study show that eight new pediatric nephrology cases are seen on the average each month, and thus, demonstrate a high burden of childhood kidney diseases in the region when compared with studies from the same region [1],[4],[9] and other regions in the country.[3],[5],[6],[7],[8] The pattern of renal diseases among children shown by this study most likely reflects the true pattern of pediatric renal diseases in northern Nigeria, since the hospital is a major referral center for pediatric kidney diseases in the region.

This study was the first to determine the pattern of renal diseases among children presenting at the pediatric nephrology clinic of the hospital, and to the best of our knowledge, the first in the region. Most of the studies on the prevalence and pattern of renal diseases among children were carried out among hospitalized patients and not clinic cases. Garba et al.[1] in Gusau, Abdurrahman et al.[4] in Zaria, and Abdullahi [9] in Birnin Kudu, all of the same northwestern region, reported on admitted cases. Ladapo et al.[5] and Onifade [12] in Lagos, Adedoyin et al.[6] in Ilorin, Ezeonwu et al.[7] in Asaba, and Ibeneme et al.[8] in Umuahia, all showed varying prevalence and patterns of renal diseases among children admitted into their respective centers. In Port Harcourt, Eke et al.[3] studied both outpatients and inpatients. The pattern of renal diseases seen in the clinic may be comparable to that of hospitalized cases in the hospital because a large proportion of patients admitted into the pediatric nephrology unit are admitted through the outpatient clinic. This was the case in Dhaka,[2] Port Harcourt,[3] and Islamabad [18] where the pattern of renal diseases seen in the outpatient clinic and that of the hospitalized cases were similar. In both inpatient and outpatient groups in these three centers, the most common renal diseases were nephrotic syndrome, UTI, and AGN.

This study demonstrated a higher burden of renal diseases among boys than girls. This is similar to what has been found in most studies both in Nigeria and other regions of the world.[1],[2],[3],[4],[5],[7],[8],[9],[10],[11],[19] This is not surprising as renal diseases, especially the CKDs are known to be commoner in males because of the higher frequency of CAKUT in males.[20] In addition, a World Bank policy research working paper attests to the fact that there is evident son preference in sub-Saharan Africa, and particularly in Nigeria being a strong patrilineal society.[21] This may account for parents taking their sons to the hospital, in preference over their daughters. However, an epidemiological study in the community would have provided a clearer picture of the actual gender-specific prevalence.

Most patients were older than 60 months at presentation with 45% of patients aged 120--179 months. This is similar to what was found in Gusau [1] and Birnin Kudu,[9] both in north-western Nigeria and in other developing countries as shown by studies in Dhaka,[2] Nepal,[22] and Libya.[23] Although the mean age of presentation of nephrotic syndrome was about 8 months lower than the mean age of presentation of AGN, this difference was not statistically significant. This slight difference may be because of the health-seeking behavior of people in our locality. Nephrotic syndrome tends to present with very marked generalized edema which may be very worrisome to the caregivers and causing them to present earlier, unlike patients with AGN who may have only minimal edema, and hematuria may not be gross and scary. Similar difference was found in Asaba,[7] Islamabad,[18] Nepal,[19] and Libya.[23] The large proportion of patients presenting in adolescence portends a poor prognosis, strengthening the need to improve public health education for improved health-seeking behaviors.

Nephrotic syndrome, AGN, UTI, AKI, and CKD are the most frequently reported renal diseases among children in Nigeria and many other regions of the world.[1],[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[19],[24],[25] However, the distribution of these diseases differs across different regions. Nephrotic syndrome was found to be the most common kidney disease in children in this study followed by AGN, in consonance with what was found in the south-western Nigeria by Onifade [12] and Ladapo et al.[5] in Lagos, in the south-east by Ibeneme et al.[8] in Umuahia, and Okoro et al.[10] in Enugu, and in the south--south by Eke et al.[3] in Port Harcourt. Studies from other centers in north-western Nigeria showed a different pattern, with AGN being the most common followed by nephrotic syndrome in Zaria [4] and Birnin Kudu,[9] whereas UTI was the most common, followed by AGN in Gusau.[1] In Jos, north-central Nigeria, AGN was predominant followed by CKD.[11] In Islamabad, UTI was most common, followed by nephrotic syndrome in clinic patients, with a reversal in admitted patients.[18] These differences across different regions could be accounted for by the differences in genetics and the influence of environmental factors such as climate across the different regions as well as variation in subject selection between the various studies. Variations in diagnostic facilities and level of clinical expertise may also contribute to these differences in some ways. Most of the studies cited above were carried out on hospitalized patients while this study was on patients seen first at the clinic, whether hospitalized or not.

Unlike in other studies, only a few cases of UTI were reported in this study. This could be because it is not a common cause of referral to pediatric nephrologist in the hospital since most cases seen are treated at the outpatient department without need for pediatric nephrologist consultation. Previous antibiotic use which is common in our region could also account for the low prevalence of UTI in this study. In many instances, however, the patients that are referred with UTI have some background congenital anomalies of the kidneys and urinary tract (CAKUT), and these are captured as such in this study.

Nephroblastoma which has been reported frequently in many studies [5],[6],[9],[13],[25] as the most common malignancy of the kidneys in children was not reported in this study because all cases of nephroblastoma in the hospital are attended to by the pediatric hemato-oncologists and the pediatric surgeons and, therefore, not seen at the nephrology clinic.

The commonest congenital disorder of the kidneys and urinary tract in this study was ectopic kidney followed by PUV. This would be said to be rather surprising as PUV has been known to be the most common CAKUT in many reports such as those from Dhaka,[2] Port Harcourt,[3] Zaria,[4] Asaba,[7] Umuahia,[8] Nepal,[19] Khartoum,[24] and Saudi Arabia.[25] In the study center, however, being a surgery-requiring condition, the cases of PUV are usually referred directly to the urologists, and not to the pediatricians. This could also explain the reason why, in this study, more females were seen with CAKUT than males.


   Conclusion Top


This study showed a high burden of renal diseases among children in the hospital. The commonest acquired renal disease was nephrotic syndrome followed by AGN, and the commonest congenital renal disease was ectopic kidney. Boys presented more commonly with renal disease than girls. A large proportion of children presented in adolescence. This study provides data which can be useful to researchers and stakeholders in planning preventive strategies for childhood renal diseases in our society.

Limitations of the study

It was a retrospective study, and hence some records could have been missing, or data captured incorrectly. The result of this study does not represent a complete picture of the pattern of renal diseases among children in the hospital because some patients were admitted directly into the emergency pediatric unit and never get to the clinic. In addition, some cases are referred directly to the surgical subspecialties. Being a hospital-based study, the findings may not be entirely representative of the actual burden of disease in the community as some patients would be taken to traditional healers and other health centers and not present to the hospital. Our findings therefore could be an underestimation. Furthermore, the study did not look at the outcomes of the various renal diseases, and this can be improved upon in subsequent studies.

Recommendations

Subsequent studies should consider both clinic cases and hospitalized patients to have a complete picture of the pattern of renal diseases among children in the hospital.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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